As part of the National Action Plan for Combating Antibiotic-Resistant Bacteria, hospitals and healthcare systems have been called upon by the White House to implement antibiotic stewardship programs by 2020. The goal of the plan is to ensure the appropriate use of antibiotics and reduce the growing emergence of resistance.
A previous guideline on antibiotic stewardship was released in 2007 and focused on the development of programs rather than on specific evidence-based strategies that have been shown to be beneficial in ensuring that such programs are effective and sustainable. The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) have recently published a new guideline in Clinical Infectious Diseases that emphasizes the use of various interventions depending on local resources, issues, and expertise.
In total, IDSA and SHEA issued 28 recommendations in the new guideline. All of these recommendations stand on their own, complete with a section of literature that supports the recommendation. The guideline was based on a review of hundreds of stewardship-focused papers that examined different strategies, “We included new studies as much as possible,” says Tamar Barlam, MD, who co-authored the update with Sara Cosgrove, MD. “For example, several recent studies show that a shorter course of antibiotics appears to be just as effective as a longer course,” she says. “A shorter but equally effective course would theoretically provide less opportunity for side effects or the emergence of resistance.”
Dr. Barlam notes that the IDSA/SHEA writing committee started with a recommendation they feel should be the first step in running an antibiotic stewardship program. “Pre-authorization, prospective audit and feedback, or both interventions should be the first step to implementing antibiotic stewardship based on studies showing that these approaches are the foundation of effective programs,” she says (Table).
Preauthorization requires physicians to consult with a member of the antibiotic stewardship team before an antibiotic can be released for their patient, according to Dr. Barlam. “This ensures that some of the antibiotics used for multi-drug-resistant infections are protected and used appropriately,” she says. “It also provides an opportunity to educate the prescriber on appropriate antibiotic use.” Prospective audits and feedback involve assessing patients’ therapy 2 to 3 days after starting an antibiotic to determine if an opportunity exists to either stop the drug or refine the coverage. Combining preauthorization with prospective review helps ensure that the right drug is prescribed at the right time for the right diagnosis.
Dr. Barlam explains that the IDSA/SHEA writing committee purposely avoided providing recommendations in a step-by-step fashion. “Different facilities can take different approaches depending on the resources of each facility, the expertise of its practitioners, and the level of support to provide stewardship,” she says. “The writing committee didn’t want to be too prescriptive. However, several recommendations can certainly be followed by almost any facility, such as changing from intravenous to oral drugs whenever appropriate. In addition, most facilities could develop treatment guidelines that are targeted to their unique patient population and on their baseline resistance patterns.” Dr. Barlam adds that the writing committee examined the literature from a practical perspective, through the lens of whether or not a program could actually implement a given strategy.
The IDSA/SHEA writing committee recommends against the use of didactic education alone in providing antibiotic stewardship. “Occasional grand rounds, speaking about antibiotics over lunch, or distributing brochures is not real stewardship,” says Dr. Barlam. “Greater efforts are necessary to improve prescribing and change practices. Antibiotic stewardship should be integrated into the facility’s culture, with infectious disease specialists guiding strategies that have been shown to work.”
Reducing the use of antibiotics associated with Clostridium difficile infection, using computerized clinician decision support if available and affordable, and implementing antibiotic “time outs” are among other recommendations made in the guideline. Additionally, clinicians and hospitals are urged to implement other strategies to encourage prescribers to perform routine reviews of antibiotic regimens.
A Big Responsibility
Individual prescribers should feel a responsibility to deescalate or stop any unnecessary antibiotics, according to Dr. Barlam. “Clinicians should understand that antibiotic resistance is not just an issue for society,” she says. “It’s a problem at the individual patient level. There are plenty of ways for clinicians to get involved with stewardship because there are so many different types of interventions. Ultimately, it is the responsibility of every prescriber to understand that how they prescribe antibiotics is an important matter and that they need to strive to prescribe them as appropriately as possible.”